Polyhydroxylated Bile Acids for Treatment of Biliary Disorders

ABSTRACT

The invention provides, in part, polyhydroxylated bile acids for treating biliary disorders, for example, biliary disorders arising out of cholestasis or portal hypertension. The invention also provides, in part, polyhydroxylated bile acids for stimulating bile flow.

FIELD OF INVENTION

The present invention provides polyhydroxylated bile acids andderivatives thereof to treat biliary disorders or stimulate bile flow.More specifically, the present invention provides polyhydroxylated bileacids and derivatives thereof to treat biliary disorders leading to, orassociated with, cholestasis or portal hypertension, or to stimulatebile flow.

BACKGROUND OF THE INVENTION

Bile is a complex secretion produced by the liver. It is stored in thegall bladder and periodically released into the small intestine to aidin digestion. Bile components include cholesterol, phospholipids, bilepigments, and various toxins that the liver eliminates throughbiliary/fecal exclusion. Bile salts are synthesized and activelysecreted across canalicular membranes providing the osmotic force todrive the flow of bile. This is the rate-limiting step for bileformation. Bile flow is essential for liver detoxification, digestion,cholesterol metabolism, and absorption of lipid-soluble nutrients andvitamins.

Bile acids are critical as carriers for elimination of cholesterol fromthe body through biliary secretion and as a detergent for the ingestionof fatty acids and fat-soluble vitamins (23). Bile acids also playimportant roles in regulating cell apoptosis/survival (37; 38; 39; 40;41) and in regulating gene expression through the farnesoid X-activatedreceptor (42; 43; 44; 45; 46; 47) in hepatocytes. Bile acids aresynthesized in hepatocytes from cholesterol, secreted into the bileafter being conjugated with glycine or taurine, reabsorbed in the smallintestine, and recirculated back to hepatocytes through the portal vein.Canalicular secretion of bile acids from liver into the bile is a keyprocess in the enterohepatic circulation of bile acids and itsmalfunction results in different hepatic diseases (23). If this processis disrupted, accumulation of bile acids often causes liver damage dueto detergent effects. In humans, the bile acid pool circulates 6-10times every 24 h, resulting in daily bile salt secretion of 20-40 g inabout 400 ml (51; 49).

Common bile acids found in the bile of selected mammals include thefollowing:

Bile acid skeleton

R″″-taurine or glycine

Common Name R′ R″ R″′ Commonly found in species Cholic acid α-OH α-OH Hbear, cat, hamster, human (3α7α12α) mouse, pig, rabbit, ratChenodeoxycholic acid α-OH H H bear, hamster, human, pig (3α7α)Deoxycholic acid H α-OH H cat, human, rabbit (3α12α) Ursodeoxycholicacid β-OH H H bear (3α7β) Lithocholic acid H H H human, rat, mouse (3α)β-muricholic acid β-OH H β-OH mouse, rat (3α6β7β) α-muricholic acid α-OHH β-OH pig, mouse, rat (3α6α7β) Ω-muricholic acid β-OH H α-OH mouse, rat(3α6α7α)

Bile Salt Export Protein (BSEP, ABCB11, or Sister of P-glycoprotein(SPGP)), a bile canalicular ATP-binding cassette (ABC) protein, has beenidentified as the main transport system for the biliary secretion ofbile acids (50; 13). BSEP mutations in humans lead to impaired bile saltsecretion and a severe liver disease, progressive familial intrahepaticcholestasis type 2 (PFIC2) (1, 2). Bile acid secretion in PFIC2 patientsis usually less than 1% of normal (2). BSEP has also been implicated asbeing a target for drugs that cause cholestasis (3-6). BSEP mutationshave also been associated with chronic intrahepatic cholestasis, benignrecurrent intrahepatic cholestasis type 2 (BRIC 2) (7, 8) andIntrahepatic Cholestasis of Pregnancy (9, 10). Mouse Bsep transportsbile acids in the order of preference:taurochenodeoxycholate>tauroursodeoxycholate=taurocholate>glycocholate=cholate(11-16). Rat liver plasma membrane vesicles exhibit similar preference(17). The bile acid preferences and activity of BSEP are similar amonghuman, rat and mouse.

bsep knockout (KO) mice suffer a cholestatic illness with increasedmortality in pups, decreased fertility in adults, and bile flow only ¼of normal amounts (18). Residual bile flow in bsep KO mice is greaterthan that of PFIC2 patients, and the phenotype less severe, in that bsepKO mice can survive infancy and have a normal lifespan (18). The liversof bsep KO mice express elevated levels of P-glycoprotein (Mdr1a/1b) andtheir bile contains novel species of bile acid, includingtetrahydroxylated bile acids (THBAs) not normally present in mouse orhuman bile (16, 18). When fed a diet of 0.5% cholate the bsep KO micebecome severely cholestatic but at the same time secrete a large amountof bile salt into the bile. To explain this apparently contradictoryresult, a ‘rain barrel’ model was proposed, suggesting the containmentlevel of bile salt in hepatocytes depends on both the affinity of thetransporter for bile acids (K_(m)) and the rate of bile acid output(19). The bsep KO mice exhibit severe cholestasis on a cholate-enricheddiet, since their high bile flow rate and bile acid output is mediatedby a transporter whose K_(m) is not low enough to reduce accumulatedintrahepatic bile salt below toxic levels. The rain barrel modelpredicts that the alternative bile salt transporter has a lower affinityfor cholate than BSEP.

When plasma membrane vesicles from the hamster B30 cell line, containinga high level of P-glycoprotein (Mdr1, Abcb1a) were examined,ATP-dependent taurocholate transport (20) with a K_(m) of 69 μM, aboutseven-fold higher than Bsep was observed, suggesting P-glycoproteintransports taurocholate with a relatively low affinity. Analysis ofbiliary bile salt composition in bsep KO mice indicates thatP-glycoprotein favours the less hydrophobic muricholates and THBAs overthe more hydrophobic primary bile acids in both human and mouse (18,21). This may explain the differing severity of the cholestaticphenotypes in bsep KO mice and PFIC2 in humans. In the bsep KO mice,murine P-glycoprotein transports intrahepatic muricholate and THBAs,across the canalicular membranes to maintain nearly normal bile flow,resulting in a mild phenotype. Since humans do not normally synthesizemuricholate or THBAs, this option is not available to human MDR1 andresults in the severe cholestasis of PFIC2 where bile flow diminishes to1% of normal (2).

Upregulated Mdr1a/1b expression (16, 20) in the bsep knockout mice, andthe known functional redundancy of the ABCB/P-glycoprotein familysuggested a role for Mdr1 in mediating bile flow. However, while thebsep knockout mice exhibit very mild cholestasis throughout life,mdr1a^(−/−)/mdr1b^(−/−) double knockout mice are healthy, with noobvious phenotype, though they do have specific defects in biliaryexcretion of infused drugs that are known to be Mdr1 substrates (22).

Some cholestatic conditions, such as Primary Biliary Cirrhosis, aretreated by supplementation with a low-toxicity bile acid not normallyfound in human bile, ursodeoxycholate. Dietary supplementation withursodeoxycholate did not result in greater bile flow in bsep KO mice andmay even have been toxic, suggesting that BSEP is responsible for thebulk of natural ursodeoxycholate transport, and so ursodeoxycholate maynot help PFIC2 patients or anyone else suffering from a BSEPinsufficiency, whether inherited, associated with pregnancy, orresulting from adverse drug or dietary exposures.

SUMMARY OF THE INVENTION

The invention provides, in part, polyhydroxylated bile acids fortreating biliary disorders, for example, biliary disorders arising outof cholestasis or portal hypertension, or for stimulating bile flow infor example normal subjects or subjects not diagnosed with a biliarydisorder.

In one aspect, the invention provides a method of treating a biledisorder in a subject in need thereof or of stimulating bile flow in asubject, the method comprising administering an effective amount of acompound according to Formula I:

or a derivative thereof, wherein any one of R₁ to R₉ may be —H or —OH,provided that at least four of R₁ to R₉ are —OH; and R₁₀ may be —COOH or—CH₂OH.

In an alternative aspect, the invention provides a pharmaceutical ornutritional composition comprising a compound according to Formula I:

or a derivative thereof, together with a pharmaceutically orphysiologically or nutritionally acceptable carrier, wherein any one ofR₁ to R₉ may be —H or —OH, provided that at least four of R₁ to R₉ are—OH; and R₁₀ may be —COOH or —CH₂OH.

In an alternative aspect, the invention provides the use of apharmaceutical or nutritional composition according to the invention forthe preparation of a medicament for treating a biliary disorder orstimulating bile flow.

In an alternative aspect, the invention provides an article ofmanufacture comprising a compound according to Formula I:

or a derivative thereof, together with instructions for use in treatinga biliary disorder or stimulating bile flow, wherein any one of R₁ to R₉may be —H or —OH, provided that at least four of R₁ to R₉ are —OH; andR₁₀ may be —COOH or —CH₂OH.

In alternative embodiments, the compound comprises a hydrophilicitygreater than that of cholate.

In alternative embodiments, the compound is selected from the groupconsisting of a tetrahydroxylated bile acid, a pentahydroxylated bileacid, or a derivative thereof.

The tetra-hydroxylated bile acid may be a 3,6,7,12-tetrahydroxycholanoicacid, a 3,4,7,12-tetrahydroxycholanoic acid, a1,3,7,12-tetrahydroxycholanoic acid, a 2,3,7,12-tetrahydroxycholanoicacid, a 3,7,16,24-tetrahydroxycholanoic acid, or a3,7,15,24-tetrahydroxycholanoic acid, or a derivative thereof.

The 3,6,7,12-tetrahydroxycholanoic acid may be a3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid, a 3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6α,7β,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6β,7β,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6α,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, a3α,6β,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, or a3α,6β,7β,12β-tetrahydroxy-5β-cholan-24-oic acid, or a derivativethereof.

The 3,6,7,12-tetrahydroxycholanoic acid may be a3β,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid, a3β,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid, a3β,6α,7β,12α-tetrahydroxy-5β-cholan-24-oic acid, a3β,6β,7β,12α-tetrahydroxy-5β-cholan-24-oic acid, a3β,6α,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, a3β,6β,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, or a3β,6β,7β,12β-tetrahydroxy-5β-cholan-24-oic acid, or a derivativethereof.

In alternative embodiments, the compound has a preferential affinity forMDR1 when compared to BSEP e.g., the compound has a high affinity forMDR1.

In alternative embodiments, the compound may be a conjugated compound,e.g., a taurine or a glycine conjugate e.g., tauryl or glycyl conjugateof a 3α,6β,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, a tauryl or glycylconjugate of a 3α,6β,7β,12β-tetrahydroxy-5β-cholan-24-oic acid, a taurylconjugate of a 3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid, ortauryl conjugate of a 3α,6β,7β,12α-tetrahydroxy-5β-cholan-24-oic acid.

In alternative embodiments, the method may comprise administering atleast one other therapeutic or prophylactic agent e.g., an agent havingpreferential affinity for BSEP, or at least one other nutritionalsupplement. The therapeutic or prophylactic agent or nutritionalsupplement may be ursodeoxycholate or a variant or derivative thereof.

In alternative embodiments, the biliary disorder may be benign biliarystrictures, benign pancreatic disease cysts, diverticulitis, liverfibrosis, liver damage, common bile duct stones, pancreatitis,pancreatic cancer or pseudocyst, periampullary cancer, bile ductcarcinoma, primary sclerosing cholangitis, autoimmune cholangitis,extrinsic duct compression (e.g., compression due to a mass or tumor ona nearby organ), viral hepatitis, sepsis, bacterial abscess, use ofdrugs e.g., drug-induced idiosyncratic hepatotoxicity, lymphoma,tuberculosis, metastatic carcinoma, sarcoidosis, amyloidosis,intravenous feeding, primary biliary cirrhosis, primary sclerosingcholangitis, alcoholic hepatitis with or without cirrhosis, nonalcoholicsteatohepatitis, nonalcoholic fatty liver disease, chronic hepatitiswith or without cirrhosis, intrahepatic cholestasis of pregnancy,biliary calculosis, biliary dyscinesia, Sjogren syndrome, Wilson'sdisease, ischemia, toxins, alcohol, acute liver failure, α1-antitrypsindeficiency, PFIC2, Benign Recurrent Intrahepatic Cholestasis,hepatocellular carcinoma, portal hypertension, veno-occlusive disease,or hepatic vein thrombosis. The biliary disorder may arise orpotentially arise from cholestasis.

In alternative embodiments, the subject may be a human.

This summary of the invention does not necessarily describe all featuresof the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows the cholestatic phenotype of the triple knockout(mdr11b^(−/−)/mdr1a^(−/−)/1b^(−/−)) mice: a) A view of abdomens showingliver enlargement of a TKO mouse in comparison with b) a wildtype mouse;c) Periportal fibrosis in the livers of a two month old male TKO mouse(Masson trichrome staining), 40×; d) Ultrastructual changes inhepatocytes, showing dilated canalicular lumen, loss of microvilli(arrows), and retained biliary material in the form of lamellae.

FIG. 2 shows the survival rate (a) and body weight changes (b) of the“triple knockout” (bsep^(−/−)/mdr1a^(−/−)/1b^(−/−)) mice after being fed0.5% cholic acid (CA).

FIG. 3 shows the generation of “triple knockout”(bsep^(−/−)/mdr1a^(−/−)/mdr1b^(−/−)) mice: a) Crossing scheme forgenerating TKO mice. The mdr1a^(−/−)/mdr1a^(−/−) double knockout andbsep^(−/−) mice were used to generate the triply heterozygoticbsep^(+/−)/mdr1a^(+/−)/mdr1b^(+/−) mice (100% of offspring are tripleheterozygotes). The triple heterozygotes were used to producebsep^(+/−)/mdr1a^(−/−)/mdr1b^(−/−) mice (approximately ⅛ of theoffspring since the mdr1a and mdr1b genes in mice are closely linked),which were then used to generate the TKO homozygotes(bsep^(−/−)/mdr1a^(−/−)/mdr1b^(−/−)). b) A PCR screening result for theTKO mice. Lanes 1, 5 and 6 are triple knockout mice, in which only bandsfrom mutant alleles were amplified.

FIG. 4 shows the ultrastructual changes in hepatocytes of a TKO(bse_(−/−)/mdr1a^(−/−)/1b^(−/−)) mouse and an mdr1a^(−/−)/1b^(−/−)control that shows no ultrastructural liver abnormality. a) On the left,showing abnormal mitochondria of variable size with cristae that arepushed to one side with small ledges not crossing the midline. Theirmitochondrial matrix is homogeneous and granules are absent. To theright, this image shows great numbers of hypertrophied Golgi vesiclesfilled with dense material (arrow). b) The liver of anmdr1a^(−/−)/1b^(−/−) mouse showing no ultrastructural abnormalities. Thearrow points to a normal canaliculus.

FIG. 5 shows the a) relative mRNA expression of some majorliver-expressed genes in wild-type, bsep^(−/−) and TKO mice asdetermined by semi-quantitative real-time PCR. The mRNA levels werenormalized against those of ribosomal protein S15. The level of femalewild-type mRNA was set at 1. All numbers are expressed as a ratio offemale wild-type mRNA, mean±standard deviation (n=4) (16). b) The majoralternatively spliced Mdr1 (Abcb1b) transcript in the TKO mice. Thistranscript has an exon 4 deletion and results in translation of 38original amino acids followed by a frame shift, 6 novel amino acids anda premature stop codon. c) The minor Mdr1 (Abcb1b) transcript in TKOmice. This transcript has a deletion of exons 4, 5, and 6 that resultsin translation of 38 original amino acids followed by a frame shift, 12novel amino acids and a premature stop codon.

FIG. 6 shows confocal microsopic pictures immunostained for MDR1 orBSEP. MDR1 expression exhibits a strongly canalicular distribution. Thelefthand panels are the controls, a liver biopsy from an infant withorganic acidemia who did not have jaundice or cholestasis. The rightpanels are from a liver biopsy sample from a PFIC2 patient.

FIGS. 7A-B show that 3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acidstimulates bile flow rate (BFR) in wild-type mice. (A) BFR as a functionof body weight in mice after infusion of3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid (6α,7αTHBA). (B) BFR asa function of body weight in mice after infusion of cholic acid (CA)(3α,7α,12α-trihydroxy-5β-cholan-24-oic acid).

FIG. 8A-B shows HPLC (High Performance Liquid Chromatography) profilesof bile salt in the bile of a male wild type mouse before (A) and after(B) infusion of unconjugated 3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oicacid (6α,7αTHBA, 100 μmol/kg as a function of body weight). (C) showsHPLC profiles of bile fractions collected from a wild-type mouse before(upper trace), and 2-4 minutes after (lower trace), infusion (100μmol/kg) of cholic acid (3α,7α,12α-trihydroxy-5β-cholan-24-oic acid).The bile samples were collected from a wild type mouse by bile ductcannulation. Equal volumes of bile were loaded.

FIG. 9 shows synthetic steps for production of3α,6α7α12α-tetrahydroxy-5β-cholanoic acid (6α,7αTHBA) from cholic acid.

FIG. 10 shows synthetic steps for production of taurine-conjugated3α,6α7α12α-tetrahydroxy-5β-cholanoic acid.

FIG. 11 shows 1H-NMR spectrum of taurine-conjugated3α,6α7α12α-tetrahydroxy-5β-cholanoic acid (18), produced by the methodshown in FIG. 10.

FIG. 12A-C shows induction of bile flow rate (BFR) by THBA in wild-typemice. (A) BFR as a function of body weight (BW) before and after theinfusion of 3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid (6β,7αTHBA) of 65 (∘,open circle), 250 (*star), 350 (▴, solid triangle) and 400 (▪, solidsquare) μmol/kg BW. (B). BFR as a function of body weight before andafter the infusion of 3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid(6α7αTHBA) of 65 (∘, open circle) and 200 (▪, solid square) μmol/kg BW.(C). BFR as a function of body weight before and after the infusion of65 μmol/kg body weight of 6β,7αTHBA (▪, solid square), 6α,7αTHBA (▴,solid triangle) and ursodeoxycholic acid (UDC) (∘, open circle). Resultsare represented as the mean±the standard deviation of three mice. UDC at65 μmol/kg body weight is the maximum tolerated dose (MTD) in the mice.

DETAILED DESCRIPTION

The present invention provides, in part, polyhydroxylated bile acids asagents of bile salt therapy to promote or improve biliary secretion insubjects with biliary disorders. Compounds according to the inventioncan be used in combination with the existing compounds, such asursodeoxycholate or a variant or derivative thereof, to improve liverfunction and/or ameliorate a bile disorder. The polyhydroxylated bileacids of the invention are choleretic (possess bile flow-stimulatingproperties) when administered to a subject e.g., a child awaiting livertransplantation. In alternative embodiments, the invention providespolyhydroxylated bile acids for stimulating bile flow in any subject,for example, a subject not diagnosed with a biliary disorder. By“stimulating bile flow” is meant increasing bile flow in a subjectrelative to a standard (e.g., standard levels of bile acid in anorganism), or relative to the level of bile measured in the subjectprior to administration of a polyhydroxylated bile acid according to theinvention. The increase may be a change of any integer value between 5%and 95%, or between 10% and 90%, or between 30% and 60%, or may be over100%. As used herein, a subject may be a human, non-human primate, rat,mouse, cow, horse, pig, sheep, goat, dog, cat, etc. The subject may be aclinical patient, a clinical trial volunteer, an experimental animal,etc. The subject may be suspected of having or at risk for having abiliary disorder, be diagnosed with a biliary disorder, or be subjectconfirmed to not have a biliary disorder. Diagnostic methods for biliarydisorders and methods for measurement of bile flow, as well as theclinical delineation of biliary disorder diagnoses, are known to thoseof ordinary skill in the art.

Biliary Disorders

Biliary disorders include any disorder or condition that can beameliorated, treated or prevented by the administration of apolyhydroxylated bile acid. Exemplary biliary disorders may includewithout limitation bile deficiency, bile toxicity, digestive disorders,impaired liver function, cholestasis, portal hypertension, etc.

Cholestasis refers to a condition in which the flow of bile from theliver is reduced or blocked, or in which there is a failure in bileflow. Bile flow failures may arise anywhere in the hepatic and biliarysystem. In general, cholestasis may be extrahepatic cholestasis, whichoccurs outside the liver cells, or may be intrahepatic cholestasis,which occurs inside the liver cells.

Extrahepatic cholestasis can result from benign biliary strictures,benign pancreatic disease cysts, diverticulitis, liver damage, commonbile duct stones, pancreatitis, pancreatic cancer or pseudocyst,periampullary cancer, bile duct carcinoma primary sclerosingcholangitis, extrinsic duct compression, for example, compression due toa mass or tumor on a nearby organ.

Intrahepatic cholestasis can be caused by viral hepatitis including butnot limited to Hepatitis B and C, sepsis, bacterial abscess, drugs e.g.,drug-induced idiosyncratic hepatotoxicity, lymphoma, tuberculosis,metastatic carcinoma, sarcoidosis, amyloidosis, intravenous feeding,primary biliary cirrhosis, primary sclerosing cholangitis, alcoholichepatitis with or without cirrhosis, chronic hepatitis with or withoutcirrhosis, pregnancy, Sjogren syndrome, etc. Drug-induced cholestasis isthe blockage of the flow of bile from the liver caused by medication,and may be caused by: gold salts, nitrofurantoin, anabolic steroids,oral contraceptives, chlorpromazine, prochlorperazine, sulindac,cimetidine, erythromycin, tobutamide, imipramine, ampicillin and otherpenicillin-based antibiotics, etc. Drug-induced cholestasis andhepatotoxicity are common obstacles to drug therapy in the clinic andpose major problems for drug development and for novel applications ofapproved drugs. Drug-induced cholestasis also accounts for 2-5% ofpatients hospitalized with jaundice, ˜10% of all cases of acutehepatitis, and over 50% of acute liver failure.

Cholestasis may also result from inherited cholestatic liver disease,from drug-induced cholestasis arising from the BSEP-inhibitory activityof certain drugs, and acute hepatotoxic reactions brought about by drugsand inflammatory conditions which impact liver function.

Portal hypertension refers to a disorder manifesting as increasedpressure in the portal vein, which is the vein that conducts blood fromthe intestine to the liver. The increased pressure in the portal veinmay be due to a variety of causes, including inflammation, fibrosis,splenic arteriovenous fistulae, splenic or portal vein thrombosis,massive splenomegaly, sarcoidosis, schistosomiasis, nodular regenerativehyperplasia, primary biliary cirrhosis, hepatitis, autoimmune disease,etc.

A biliary disorder according to the invention is any disorder arising,or potentially arising, from cholestasis, portal hypertension, or anydisorder benefited by the administration of a poly-hydroxylated bileacid as described herein. Biliary disorders include without limitationbenign biliary strictures, benign pancreatic disease cysts,diverticulitis, liver fibrosis, liver damage, common bile duct stones,pancreatitis, pancreatic cancer or pseudocyst, periampullary cancer,bile duct carcinoma, primary sclerosing cholangitis, autoimmunecholangitis, extrinsic duct compression (e.g., compression due to a massor tumor on a nearby organ, viral hepatitis (e.g., Hepatitis A, B, C, D,E, herpes simplex, cytomegalovirus, Epstein-Barr, adenovirus), sepsis,bacterial abscess, use of drugs e.g., drug-induced idiosyncratichepatotoxicity, lymphoma, tuberculosis, metastatic carcinoma,sarcoidosis, amyloidosis, intravenous feeding, primary biliarycirrhosis, primary sclerosing cholangitis, alcoholic hepatitis with orwithout cirrhosis, nonalcoholic steatohepatitis, nonalcoholic fattyliver disease, chronic hepatitis with or without cirrhosis, intrahepaticcholestasis of pregnancy, biliary calculosis, biliary dyscinesia,Sjogren syndrome, Wilson's disease, ischemia, toxins, alcohol, acuteliver failure, α1-antitrypsin deficiency, PFIC2, Benign RecurrentIntrahepatic Cholestasis (BRIC), hepatocellular carcinoma (HCC), portalhypertension, veno-occlusive disease, hepatic vein thrombosis, etc.

Polyhydroxylated Bile Acids and Derivatives Thereof

Bile acids are amphipathic compounds derived from cholesterol and are asubclass of steroids. Bile acids and bile alcohols are steroids whosestructure is related to cholane or cholestane; accordingly bile acidsand bile alcohols may be termed cholanoids (51). The term “bile acid” isa generic term for cholanoid molecules having a carboxyl group and doesnot denote an ionization state.

The term “bile salt” may be used for a salt in which the anion is aconjugated bile acid, an unconjugated bile acid, or a conjugate of abile alcohol, or may be used as a generic term to include bothconjugated bile acids and bile alcohol conjugates occurring in nature aswater-soluble anions (51). For example, bile salts may be bile acidsconjugated with glycine or taurine as sodium salts.

The numbering system for the carbon atoms of the bile acid skeleton, asused herein, is as follows.

C₂₄ bile acids are termed cholanoic acids or cholanoates, while C₂₇ bileacids are termed cholestanic acids or cholestanoates. In general, theconfiguration of the side chain is 17β, with a 5β hydrogen (A/B ringjunction in cis configuration). “Allo” bile acids are bile acids with a5α hydrogen (51).

Bile acids may be polyhydroxylated. A polyhydroxylated bile acidcompound according to the invention includes without limitationtetrahydroxylated bile acids, pentahydroxylated bile acids,hexahydroxylated bile acids, etc., up to the maximum level ofhydroxylation possible.

In some embodiments, a polyhydroxylated bile acid may be a compound asrepresented in Formula I:

or a derivative thereof, in which any one of R₁ to R₉ may be —H or —OH,provided that at least four of R₁ to R₉ are —OH; and R₁₀ may be —COOH or—CH₂OH.

In some embodiments, any one of R₁ to R₉ may be —H, —OH, —F, —Cl, —Br,alkyl (for example, —CH₃, —CH₂—CH₃), —SO₄, or glucose provided that atleast four of R₁ to R₉ are —OH; and R₁₀ may be —COOH or —CH₂OH.

In some embodiments, bile acids according to the invention are at leasttetrahydroxylated i.e. have four or greater than four hydroxyl groups.In some embodiments, the hydroxyl groups are present on the steroidnucleus. In some embodiments, the hydroxyl groups may also be present onthe alkyl side chain.

A tetrahydroxylated bile acid according to the invention includes,without limitation, a 3,6,7,12-tetrahydroxycholanoic acid; a3,4,7,12-tetrahydroxycholanoic acid; a 1,2,7,12-tetrahydroxycholanoicacid; a 1,3,7,12-tetrahydroxycholanoic acid; a2,3,7,12-tetrahydroxycholanoic acid; a 3,7,16,24-tetrahydroxycholanoicacid; or a 3,7,15,24-tetrahydroxycholanoic acid, or derivatives thereof.

A 3,6,7,12-tetrahydroxycholanoic acid according to the inventionincludes, without limitation, a3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid; a3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid; a3α,6α,7β,12α-tetrahydroxy-5β-cholan-24-oic acid; a3α,6β,7β,12α-tetrahydroxy-5β-cholan-24-oic acid; a3α,6α,7α,12β-tetrahydroxy-5β-cholan-24-oic acid; a3α,6β,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, or a 3α,6β,7β,12β-tetrahydroxy-5β-cholan-24-oic acid, or derivatives thereof.

A 3,4,7,12-tetrahydroxycholanoic acid according to the inventionincludes, without limitation, a3α,4β,7α,12αtetrahydroxy-5β-cholan-24-oic acid, or derivatives thereof.

A 1,3,7,12-tetrahydroxycholanoic acid according to the inventionincludes, without limitation, a1β,3α,7α,12αtetrahydroxy-5β-cholan-24-oic acid, or derivatives thereof.

A 2,3,7,12-tetrahydroxycholanoic acid according to the inventionincludes, without limitation, a2β,3α,7α,12αtetrahydroxy-5β-cholan-24-oic acid, or derivatives thereof.

A 3,7,16,24-tetrahydroxycholanoic acid according to the inventionincludes, without limitation, a 3α,7α,16α,24tetrahydroxy-5β-cholane orderivatives thereof.

A 3,7,15,24-tetrahydroxycholanoic acid, according to the inventionincludes without limitation, a 3α,7β,15α,24tetrahydroxy-5β-cholane orderivatives thereof.

In alternative embodiments, polyhydroxylated bile acid compoundsaccording to the invention include, without limitation, a3α,7α,12α,24tetrahydroxy-5β-26-oic acid; a3α,7α,12α,24tetrahydroxy-5β-Cholest-25-ene; a3α,7α,24,26tetrahydroxy-5β-Cholestane; or a3α,7α,12α,24,26pentahydroxy-5β-Cholestane or derivatives thereof.

In alternative embodiments, polyhydroxylated bile acid compoundsaccording to the invention specifically exclude beta-muricholate andtrihydroxy bile acids. In alternative embodiments, polyhydroxylated bileacid compounds according to the invention are more hydrophilic thancholate (23, 24), as measured for example by the distribution andconfigurations of polar [OH⁻] and apolar (H⁺) residues along the steroidring, or by retention times in reverse-phase HPLC (60). In someembodiments, polyhydroxylated bile acid compounds according to theinvention have a hydrophobicity of less than 0.45, 0.40, 0.35, 0.30,0.25, 0.20, 0.15, 0.10, or 0.05 relative to taurocholate (which isassigned a value of 1.0; see for example Asamoto et al. (21)).

In some embodiments, polyhydroxylated bile acid compounds according tothe invention have a preferential affinity for MDR1 when compared toBSEP. In some embodiments, polyhydroxylated bile acid compoundsaccording to the invention have a high affinity to MDR1, e.g., a Kmlower than 10 μM, 20 μM, 30 μM, 40 μM, 50 μM, 60 μM, 70 μM, 80 μM, 90μM, 100 μM or more.

The term “conjugated bile acid” may be used to indicate a bile acidconjugated to a group that gives additional hydrophilicity or charge tothe molecule. In alternative embodiments, the polyhydroxylated bile acidcompounds according to the invention include taurine and/or glycineconjugates. In alternative embodiments, the polyhydroxylated bile acidcompounds according to the invention include conjugates with any othersuitable amino acids. In alternative embodiments, the polyhydroxylatedbile acid compounds according to the invention include conjugates withsulfate, phosphate, Coenzyme A, glucuronate, glucose, xylose, and othersugars, N-acetylglucosamine, etc. For example, conjugatedpolyhydroxylated compounds according to the invention include, withoutlimitation, tauryl or glycyl conjugates of 3α,6α,7α,12β-tetrahydroxy-5β-cholan-24-oic acids, tauryl or glycyl conjugatesof 3α,6β,7β,12β-tetrahydroxy-5β-cholan-24-oic acids, tauryl conjugatesof 3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acids, tauryl conjugatesof 3α,6β,7β,12α-tetrahydroxy-5β-cholan-24-oic acids, ethanesulfonicacid, 2-[(3,6,7,12-tetrahydroxy-24-oxocholan-24- yl)amino], e.g.,ethanesulfonic acid,2-[[(3α,5β,6α,7α,12α)-3,6,7,12-tetrahydroxy-24-oxocholan-24-yl]amino]-,Glycine, N-(3,6,7,12-tetrahydroxy-24-oxocholan-24-yl) e.g., Glycine,N-[(3α,5β,6β,7β,12α)-3,6,7,12-tetrahydroxy-24-oxocholan-24-yl], Glycine,N-[(3α,5β,6β,7α,12α)-3,6,7,12-tetrahydroxy-24-oxocholan-24-yl], Glycine,N-[(3α,5β,6α,7β,12α)-3,6,7,12-tetrahydroxy-24-oxocholan-24-yl], Glycine,N-[(3α,5β,6α,7α,12α)-3,6,7,12-tetrahydroxy-24-oxocholan-24-yl], etc.

The polyhydroxylated bile acid compounds according to the inventioninclude isomers e.g., stereoisomers. For example, 3β and 5α hydroxytetrahydroxycholanoic acid are included, as are any stereoisomericconfigurations and combinations thereof.

The polyhydroxylated bile acid compounds according to the inventioninclude physiologically or pharmaceutically-acceptable derivatives, suchas salts, esters, enol ethers, enol esters, solvates, hydrates andprodrugs of the compounds described herein. Pharmaceutically-acceptablesalts, include, but are not limited to, amine salts, such as but notlimited to N,N′-dibenzylethylenediamine, chloroprocaine, choline,ammonia, diethanolamine and other hydroxyalkylamines, ethylenediamine,N-methylglucamine, procaine, N-benzylphenethylamine,1-para-chlorobenzyl-2-pyrrolidin-1′-ylmethylbenzimidazole, diethylamineand other alkylamines, piperazine and tris(hydroxymethyl)aminomethane;alkali metal salts, such as but not limited to lithium, potassium andsodium; alkali earth metal salts, such as but not limited to barium,calcium and magnesium; transition metal salts, such as but not limitedto zinc, aluminum, and other metal salts, such as but not limited tosodium hydrogen phosphate and disodium phosphate; and also including,but not limited to, salts of mineral acids, such as but not limited tohydrochlorides and sulfates; and salts of organic acids, such as but notlimited to acetates, lactates, malates, tartrates, citrates, ascorbates,succinates, butyrates, valerates and fumarates.

Compounds and salts thereof of this invention and for use in thisinvention are generally provided in substantially purified form. Acompound or salt (if naturally occurring) is “substantially pure” or“isolated” when it is separated from the components that naturallyaccompany it (e. g, cells of a source organism or tissue). A compoundmay be substantially pure or isolated when it is substantially free ofcellular contaminants, i. e, that it is present ex vivo and in aconcentration greater than that of the compound in a source organism,tissue, or other natural source. Typically, a compound is substantiallypure or isolated when it is at least 10%, 20%, 30%, 40%, 50%, or 60%,more generally 70%, 75%, 80%, or 85%, or over 90%, 95%, or 99% byweight, of the total material in a sample. Thus, for example, a compoundthat is chemically synthesized will generally be substantially free fromits naturally associated components. A substantially pure compound canbe obtained, for example, by extraction from a natural source or bychemical synthesis. A substantially pure compound may includestereoisomers or differentially hydroxylated mixtures. Purity can bemeasured using any appropriate method such as column, gas, or liquidchromatography or mass spectrometry.

In an alternate embodiment of the invention, a composition comprising aracemic mixture of a tetrahydroxylated bile acid is provided. Theracemic mixture may be produced as a result of the chemical synthesis ofthe tetrahydroxylated bile acid; alternately, two or morestereochemically pure enantiomers may be combined. In anotherembodiment, the composition may comprise two or more tetrahydroxylatedbile acids.

Preparation of Polyhydroxylated Bile Acids

Compounds according to the invention, or for use according to theinvention, including pharmaceutically acceptable salts or derivativesthereof, may be obtained by synthesis making use of common procedures asexemplified herein or known in the art. Some compounds that may be usedaccording to the invention can be obtained from natural sources. Forexample, polyhydroxylated bile acid compounds may be prepared in part orin whole from natural sources, e.g., by fractionating biologicalextracts (e.g , from bsep KO mice). Bile acids may be obtained from bsepKO mice by for example using bile duct cannulation to collect about10-20 ml bile from 50-100 bsep KO mice. HPLC may be used to isolateabout 10-20 μmol (5-10 mg) tetra-hydroxylated bile acid. In someembodiments, polyhydroxylated bile acid compounds according to theinvention may be prepared by total synthesis. Such synthetic compoundscan, optionally, be labeled or derivatized for analytical or drugdevelopment purposes

The compounds may be synthesized using standard techniques such as thosedescribed in Tohma et al., 1985 (52); Iida et al, 1991a (53); Iida etal., 1991b (54); Aggarwal et al., 1992 (55); Iida et al., 1993 (56);Kurosawa et al, 1995 (57); Kurosawa et al., 1996 (58); Iida et al, 2002(59); etc., all of which are specifically incorporated by reference. Forexample, tetrahydroxy bile acids may be prepared as indicated in Tohmaet al., 1985 (52); Iida et al., 1991b (54); Aggarwal et al., 1992 (55);Iida et al., 1993 (56); Kurosawa et al., 1996 (58); Iida et al, 2002(59); pentahydroxy bile acids may be prepared as indicated in Kurosawaet al., 1996 (58).

Pharmaceutical or Nutritional Supplement Compositions, Dosages, andAdministration of Poly-Hydroxylated Bile Acids

The polyhydroxylated bile acid compounds of the invention can beprovided alone or in combination with other compounds (for example,nucleic acid molecules, small molecules, peptides, or peptideanalogues), in the presence of a liposome, an adjuvant, or anypharmaceutically or physiologically acceptable carrier, in a formsuitable for administration to humans or animals. If desired, treatmentwith a compound according to the invention may be combined with moretraditional and existing therapies for biliary disorders or disordersresulting in or potentially resulting in hepatotoxicity, or withexisting nutritional supplements for stimulating bile flow. In someembodiments, polyhydroxylated bile acids according to the invention areadministered to subjects not diagnosed with a biliary disorder (e.g., anormal subject) to stimulate bile flow. In some embodiments,polyhydroxylated bile acids according to the invention are administeredunder conditions where BSEP is inhibited and where the approvedtherapeutic agent for cholestasis, ursodeoxycholate, is ineffective. Insome embodiments, polyhydroxylated bile acids according to the inventionare administered together with ursodeoxycholate or a variant orderivative thereof (e.g., sulfated ursodeoxycholate, nitrodeoxycholate,taurodeoxycholate, etc.), Rifampicin, or any compound useful fortreating cholestasis or portal hypertension or for stimulating bileflow.

Conventional pharmaceutical or nutritional supplement formulationpractice may be employed to provide suitable formulations orcompositions to administer the compounds to patients suffering from orpresymptomatic for cholestasis, or to normal subjects for stimulatingbile flow. Any appropriate route of administration may be employed, forexample, parenteral, intravenous, subcutaneous, intramuscular,intracranial, intraorbital, ophthalmic, intraventricular, intracapsular,intraspinal, intracistemal, intraperitoneal, intranasal, aerosol, ororal administration. Therapeutic formulations may be in the form ofliquid solutions or suspensions; for oral administration, formulationsmay be in the form of tablets or capsules; and for intranasalformulations, in the form of powders, nasal drops, or aerosols.

Methods well known in the art for making formulations are found in, forexample, “Remington's Pharmaceutical Sciences” (19th edition), ed. A.Gennaro, 1995, Mack Publishing Company, Easton, Pa. Formulations forparenteral administration may, for example, contain excipients, sterilewater, or saline, polyalkylene glycols such as polyethylene glycol, oilsof vegetable origin, or hydrogenated napthalenes. Biocompatible,biodegradable lactide polymer, lactide/glycolide copolymer, orpolyoxyethylene-polyoxypropylene copolymers may be used to control therelease of the compounds. Other potentially useful parenteral deliverysystems for modulatory compounds include ethylene-vinyl acetatecopolymer particles, osmotic pumps, implantable infusion systems, andliposomes. Formulations for inhalation may contain excipients, forexample, lactose, or may be aqueous solutions containing, for example,polyoxyethylene-9-lauryl ether, glycocholate and deoxycholate, or may beoily solutions for administration in the form of nasal drops, or as agel.

For therapeutic or prophylactic compositions, the compounds areadministered to a subject in an amount sufficient to stop or slowcholestasis or to maintain or increase bile flow or to ameliorate portalhypertension. For nutritional supplements, the compounds areadministered to a subject in an amount sufficient to stimulate bileflow.

As discussed herein, a significant upregulation of MDR1 expression wasfound in livers of PFIC patients, indicating that MDR1 can be targetedin drug therapy for cholestatic diseases such as PFIC2 and other biliarydisorders indicated herein. BSEP and MDR1 are loci of significantpolymorphism in human populations, and some BSEP variants are associatedwith susceptibility to liver diseases. For example, the V444Apolymorphism in BSEP is present in about half the population and isassociated with a ˜60% increased risk of intrahepatic cholestasis ofpregnancy. Other forms of biliary disorders manifesting elevated MDR1expression can also be treated using the compounds according to theinvention. Compounds according to the invention can also providetherapeutic benefit to patients suffering from inherited cholestaticliver disease, from drug-induced cholestasis arising from theBSEP-inhibitory activity of certain drugs, or from other biliarydisorders, and can help alleviate acute hepatotoxic reactions broughtabout by drugs and inflammatory conditions which impact biliaryfunction.

An “effective amount” of a compound according to the invention includesa therapeutically effective amount or a prophylactically effectiveamount or a nutritionally effective amount. A “therapeutically effectiveamount” refers to an amount effective, at dosages and for periods oftime necessary, to achieve the desired therapeutic result, such asincreased bile flow, relief of jaundice, or improved liver functions asindicated by normalization of serum liver biochemical indicators, suchas the levels of bilirubins, ALP (alkaline phosphatase), ALT (alanineaminotransferase), AST (aspartate aminotransferase) , γ-GT(Gamma-Glutamyl Transpeptidase), etc. A therapeutically effective amountof a compound may vary according to factors such as the disease state,age, sex, and weight of the individual, and the ability of the compoundto elicit a desired response in the individual. Dosage regimens may beadjusted to provide the optimum therapeutic response. A therapeuticallyeffective amount is also one in which any toxic or detrimental effectsof the compound are outweighed by the therapeutically beneficialeffects. A “prophylactically effective amount” refers to an amounteffective, at dosages and for periods of time necessary, to achieve thedesired prophylactic result, such as increased bile flow or improvedliver functions as indicated by liver biochemical indicators, increasedbile flow, relief of jaundice, or improved liver functions as indicatedby normalization of serum liver biochemical indicators, such as thelevels of bilirubins, ALP (alkaline phosphatase), ALT (alanineaminotransferase), AST (aspartate aminotransferase), γ-GT(Gamma-Glutamyl Transpeptidase), etc. Typically, a prophylactic dose isused in subjects prior to or at an earlier stage of disease, so that aprophylactically effective amount may be less than a therapeuticallyeffective amount. An exemplary range for therapeutically orprophylactically effective amounts of a compound may be 5-50 mg/day/kgof body weight of the subject e.g., a human. A “nutritionally effectiveamount” refers to an amount effective, at dosages and for periods oftime necessary, to achieve the desired result, such as increased bileflow or improved liver functions as indicated by liver biochemicalindicators.

It is to be noted that dosage values may vary with the severity of thecondition to be alleviated. For any particular subject, specific dosageregimens may be adjusted over time according to the individual need andthe professional judgment of the person administering or supervising theadministration of the compositions. Dosage ranges set forth herein areexemplary only and do not limit the dosage ranges that may be selectedby medical practitioners. The amount of active compound in thecomposition may vary according to factors such as the disease state,age, sex, and weight of the individual. Dosage regimens may be adjustedto provide the optimum therapeutic response. For example, a single bolusmay be administered, several divided doses may be administered over timeor the dose may be proportionally reduced or increased as indicated bythe exigencies of the therapeutic situation. It may be advantageous toformulate parenteral compositions in dosage unit form for ease ofadministration and uniformity of dosage.

In the case of vaccine formulations, an immunogenically effective amountof a compound of the invention can be provided, alone or in combinationwith other compounds, with an adjuvant, for example, Freund's incompleteadjuvant or aluminum hydroxide. The compound may also be linked with acarrier molecule, such as bovine serum albumin or keyhole limpethemocyanin to enhance immunogenicity.

For nutritional supplements, at least one additive, including one listedbelow, can be included for consumption with the nutritional supplementof the invention and may have, for example, antioxidant, dispersant,antimicrobial, or solubilizing properties. A suitable antioxidant is,for example, vitamin C, vitamin E or rosemary extract. A suitabledispersant is, for example, lecithin, an alkyl polyglycoside,polysorbate 80 or sodium lauryl sulfate. A suitable antimicrobial is,for example, sodium sulfite or sodium benzoate. A suitable solubilizingagent is, for example, a vegetable oil such as sunflower oil, coconutoil, and the like, or mono-, di- or tri-glycerides. Additives includevitamins such as vitamin A (retinol, retinyl palmitate or retinolacetate), vitamin B1 (thiamin, thiamin hydrochloride or thiaminmononitrate), vitamin B2 (riboflavin), vitamin 133 (niacin, nicotinicacid or niacinamide), vitamin B5 (pantothenic acid, calciumpantothenate, d-panthenol or d-calcium pantothenate), vitamin B6(pyridoxine, pyridoxal, pyridoxamine or pyridoxine hydrochloride),vitamin B12 (cobalamin or cyanocobalamin), folic acid, folate, folacin,vitamin H (biotin), vitamin C (ascorbic acid, sodium ascorbate, calciumascorbate or ascorbyl palmitate), vitamin D (cholecalciferol, calciferolor ergocalciferol), vitamin E (d-alpha-tocopherol, d-beta-tocopherol,d-gamma-tocopherol, d-delta-tocopherol or d-alpha-tocopheryl acetate)and vitamin K (phylloquinone or phytonadione). Other additives includeminerals such as boron (sodium tetraborate decahydrate), calcium(calcium carbonate, calcium caseinate, calcium citrate, calciumgluconate, calcium lactate, calcium phosphate, dibasic calcium phosphateor tribasic calcium phosphate), chromium (GTF chromium from yeast,chromium acetate, chromium chloride, chromium trichloride and chromiumpicolinate) copper (copper gluconate or copper sulfate), fluorine(fluoride and calcium fluoride), iodine (potassium iodide), iron(ferrous fumarate, ferrous gluconate or ferrous sulfate), magnesium(magnesium carbonate, magnesium gluconate, magnesium hydroxide ormagnesium oxide), manganese (manganese gluconate and manganese sulfate),molybdenum (sodium molybdate), phosphorus (dibasic calcium phosphate,sodium phosphate), potassium (potassium aspartate, potassium citrate,potassium chloride or potassium gluconate), selenium (sodium selenite orselenium from yeast), silicon (sodium metasilicate), sodium (sodiumchloride), strontium, vanadium (vanadium sulfate) and zinc (zincacetate, zinc citrate, zinc gluconate or zinc sulfate). Other additivesinclude amino acids, peptides, and related molecules such as alanine,arginine, asparagine, aspartic acid, carnitine, citrulline, cysteine,cystine, dimethylglycine, gamma-aminobutyric acid, glutamic acid,glutamine, glutathione, glycine, histidine, isoleucine, leucine, lysine,methionine, ornithine, phenylalanine, proline, serine, taurine,threonine, tryptophan, tyrosine and valine. Other additives includeanimal extracts such as cod liver oil, marine lipids, shark cartilage,oyster shell, bee pollen and d-glucosamine sulfate. Other additivesinclude unsaturated free fatty acids such as linoleic, arachidonic andlinolenic acid, which may be in an ester (e.g. ethyl ester ortriglyceride) form. Other additives include herbs and plant extractssuch as kelp, pectin, Spirulina, fiber, lecithin, wheat germ oil,safflower seed oil, flax seed, evening primrose, borage oil,blackcurrant, pumpkin seed oil, grape extract, grape seed extract, barkextract, pine bark extract, French maritime pine bark extract, muirapuama extract, fennel seed extract, dong quai extract, chaste tree berryextract, alfalfa, saw palmetto berry extract, green tea extracts,angelica, catnip, cayenne, comfrey, garlic, ginger, ginseng, goldenseal,juniper berries, licorice, olive oil, parsley, peppermint, rosemaryextract, valerian, white willow, yellow dock and yerba mate. Otheradditives include enzymes such as amylase, protease, lipase and papainas well as miscellaneous substances such as menaquinone, choline(choline bitartrate), inositol, carotenoids (beta-carotene,alpha-carotene, zeaxanthin, cryptoxanthin or lutein), para-aminobenzoicacid, betaine HCl, free omega-3 fatty acids and their esters, thioticacid (alpha-lipoic acid), 1,2-dithiolane-3-pentanoic acid,1,2-dithiolane-3-valeric acid, alkyl polyglycosides, polysorbate 80,sodium lauryl sulfate, flavanoids, flavanones, flavones, flavonols,isoflavones, proanthocyanidins, oligomeric proanthocyanidins, vitamin Aaldehyde, a mixture of the components of vitamin A₂, the D Vitamins (D₁,D₂, D₃ and D₄) which can be treated as a mixture, ascorbyl palmitate andvitamin K₂. The nutritional supplement of the invention is typically aviscous oil and can be added to a foodstuff composition duringprocessing of the foodstuff. Such a foodstuff composition is oftenreferred to as a functional food, and can be any food that will toleratethe physicochemical properties of the nutritional supplement, forexample, margarine, cooking oil, shortening or mayonnaise. It can alsobe packaged for consumption in softgel, capsule, tablet or liquid form.It can be supplied in edible polysaccharide gums, for examplecarrageenan, locust bean gum, guar, tragacanth, cellulose andcarboxymethylcellulose.

In general, compounds of the invention should be used without causingsubstantial toxicity. Toxicity of the compounds of the invention can bedetermined using standard techniques, for example, by testing in cellcultures or experimental animals and determining the therapeutic index,i.e., the ratio between the LD50 (the dose lethal to 50% of thepopulation) and the LD 100 (the dose lethal to 100% of the population).Other methods that may be used to determine toxicity of the compounds ofthe invention include, but are not limited to, histological abnormalityby H&E staining, trichrome staining or the like; changes in bile flowrate, and/or clearance of other bile substances (for example, asdetermined by bile duct cannulation); HPLC analysis, enzymatic assays orthe like; changes in liver indicator profiles, for example level ofbilirubins, level of ALP (alkaline phosphatase), level of ALT (alanineaminotransferase), level of AST (aspartate aminotransferase), level ofγ-GT (Gamma-Glutamyl Transpeptidase), or the like. The maximum tolerateddose (MTD) is the highest regularly administered dose of a compound orcomposition that does not cause overt toxicity (e.g. does not causeunacceptable side effects) in a subject study over a period of time. Thesubject may be a human, or an animal, such as a mouse or a rat, forexample. The regularly administered dose may be a daily dose,administered as a single bolus; alternately the daily dose may bedivided into two or more partial doses so that the subject receives thetotal daily dose over time. The period of time of the study may varyfrom a few days to a few months, for example 10, 20, 30, 60, 90 or 120days, or any amount therebetween. Examples of overt toxicity mayinclude, but are not limited to, appreciable death of cells or organdysfunction, toxic manifestations that are predicted materially toreduce the life span of the subject, or 10% or greater retardation ofbody weight gain.

In some circumstances however, such as in severe disease conditions, itmay be necessary to administer substantial excesses of the compositions.In some embodiments, 3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid or3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid may have lower toxicitythan other bile acids, for example ursodexoxycholate. When used as anutritional supplement, the appropriate dose should not result insignificant toxicity.

Articles of Manufacture

Articles of manufacture containing packaging material, apolyhydroxylated bile acid compound or composition, or pharmaceuticallyor physiologically acceptable derivative thereof, provided herein, whichis effective for stimulating bile flow or for modulating the activity ofMDR1, or for treatment, prevention or amelioration of one or moresymptoms of cholestasis or biliary disorders in which MDR1 isimplicated, within the packaging material, and a label that indicatesthat the compound or composition, or pharmaceutically acceptablederivative thereof, is used for stimulating bile flow or for modulatingthe activity of MDR1, or for treatment, prevention or amelioration ofone or more symptoms of cholestasis or biliary disorders in which MDR1is implicated, are provided.

Kits

A kit comprising a polyhydroxylated bile acid compound, or compositioncomprising a polyhydroxylated bile acid compound, or pharmaceutically orphysiologically acceptable derivatives thereof, provided herein, whichis effective for stimulating bile flow or for modulating the activity ofMDR1, or for treatment, prevention or amelioration of one or moresymptoms of cholestasis or biliary disorders in which MDR1 isimplicated, along with instructions for use of the compound orcomposition, is provided. The kit may be useful for treating a biliarydisorder in a subject, and the instructions may include, for example,dose concentrations, dose intervals, preferred administration methods orthe like.

In another embodiment, the kit may be useful for the preparation of amedicament, and the instructions may comprise instructions for thepreparation of the medicament. The kit may further comprise instructionsfor use of the medicament in treatment for treatment, prevention oramelioration of one or more symptoms of cholestasis or biliary disordersin which MDR1 is implicated, and include, for example, doseconcentrations, dose intervals, preferred administration methods or thelike.

In another embodiment, the kit may be useful for the preparation of apharmaceutical or nutritional composition, and the instructions maycomprise instructions for the preparation of the pharmaceutical ornutritional composition. The kit may further comprise instructions foruse of the pharmaceutical or nutritional composition for treatment,prevention or amelioration of one or more symptoms of cholestasis orbiliary disorders in which MDR1 is implicated, and include, for example,dose concentrations, dose intervals, preferred administration methods orthe like.

The present invention will be further illustrated in the followingexamples.

EXAMPLE 1 Animal Model for Cholestasis

Methods

Animals

As described previously, the bsep KO mice on an FVB/NJ geneticbackground (16) were maintained in this laboratory and mdr1a/1b KO mice(22) were from Taconic (Hudson, N.Y. 12534). Mice were maintained in a12-hour light and dark cycle, at 22° C., with free access to food andwater. The mice were fed a normal diet except where specified otherwisein the results. Experiments were performed using approved protocols ofthe Committee on Animal Care, University of British Columbia, accordingto the guidelines of the Canadian Council on Animal Care.

Light and Transmission Electron Microscopy

For light microscopy, mice were killed with CO₂ after 2-4 hours offasting. Livers were immediately removed and transferred into 10%neutral buffered formalin followed by paraffin sectioning andhematoxylin-eosin staining or Masson trichrome staining (Wax-itHistology Services Inc, Vancouver). For transmission electronmicroscopy, livers were perfusion-fixed in-situ using ice-cold 2.5%glutaraldehyde and kept in 2.5% glutaraldehyde. Dehydration,plastic-embedding and sectioning were performed as described previously(25). One micron-thick plastic-embedded sections were also obtained andexamined in a Philips EM400T transmission electron microscope(Eindhoven, The Netherlands).

Human Liver Samples

Five needle biopsy or surgical biopsy liver samples from geneticallyconfirmed PFIC type 1 and 2 patients¹ aged 5 months to 1.5 years of agewere obtained. Two PFIC-2 patients were sibling pairs with aheterozygous V284L mutation and a 1 bp deletion at nucleotide position1273. The other PFIC-2 patient had a G1004D missense mutation. ThreePFIC-3 patients were included by virtue of having high γ-GT PFIC,including one confirmed deletion mutation in the MDR3 gene (Chen H L etal., Pediatric Research 50:50-55). Another 6 age-matched controls (0.5to 1.5 years) from non-jaundiced, non-cholestatic metabolic liverdisease or hepatitis patients. Samples were collected under informedconsent.

Quantitative Reverse-Transcription PCR

Liver samples from mice and patients were used to prepare RNA aspreviously described (16). Briefly, total RNAs were extracted fromfrozen liver by the RNAeasy kit (Qiagen GmbH, Hilden, Germany). 1-10 μgof total RNA was reverse-transcribed with 200 pmol of random hexamer(Promega Corp., Madison, Wis.) and reverse transcriptase (SuperScriptII, Invitrogen Life Technologies, Breda, Netherlands) at 42° C. for 50min and inactivated at 72° C. for 15 min. With the complementary DNA(cDNA) obtained, for mouse samples, PCR reactions were done with theSYBR Green PCRMaster Mix (Foster City, Calif.) in a PRISM 7900HTSequence Detection System (Applied Biosystems, Foster City, Calif.),using the “Standard Curve Method”(ABI PRISM User Bulletin 2). Primersused were as reported previously (16). For each sample, aliquots (5-10ng) of total RNA were used for each RT-PCR reaction, and the resultswere normalized against the expression level of ribosomal protein S15(Rps15). For patient samples, PCR reactions were performed using theTaqman system. Aliquots (5 ng) of total RNA were used for each RT-PCRreaction. The expression levels of MDR relative to TATA box-bindingprotein (TBP) were calculated using the dCT method (ABI PRISM UserBulletin 2). The primers and probes used were: MDR (Hs00184500_m1, ABI)and TBP (sense: 5′-CACGAACCACGGCACTGTT-3′ (SEQ ID NO: 1); antisense:5′-TTTTCTTGCTGCCAGTCTGGAC-3′ (SEQ ID NO: 2); probe 5′-JOETGTGCACAGGAGCCAAGAGTGAAGA-3′ (SEQ ID NO: 3)).

Immunofluorescent Staining

Samples of fresh liver tissue were embedded in O.C.T. compound(Tissue-Tek; SAKURA) immediately. Frozen tissue sections (˜5-7 μm) werecut with a cryostat and placed on poly-L-lysine-coated glass slides,then fixed in cooled acetone for 10 minutes. A rabbit polyclonalantibody against human BSEP (1:500) was used as previously reported(26). Monoclonal antibodies against human MDR with 1:500 dilution(Sigma, Saint Louis Mo.) were used. After rinsing with PBS, the tissuesections were incubated with fluorescent-conjugated secondary antibodyto either rabbit or mouse IgG (Alexa Fluor 594 and Alexa Fluor 488, LifeTechnologies) for 1 hour at room temperature, followed by PBS washing.The sections were mounted with VectaShield (Life Technologies). Imageswere obtained using a Nikon C1 confocal microscope and processed usingPhotoimpact 8.0 software (Ulead).

Results

Triple knockout (TKO) mice carrying null mutations of mdr1a and mdr1b(co-orthologs of human MDR1) and bsep genes by multi-step crossing ofbsep^(−/−) mice (18) with mdr1a^(−/−)/mdr1b^(−/−) double knockout mice(22) were generated FIG. 3 a). Null expression of the three mutant genesin the TKO mice was confirmed by genomic PCR (FIG. 3 b), real timeRT-PCR (FIG. 5), and Western blotting.

The TKO mice displayed more severe cholestasis than either parentalstrain, manifesting as severe jaundice e.g., on the body wall and paws,throughout life, liver enlargement (FIG. 1 a), disrupted canaliculi(FIG. 1 d), blocked bile ducts, growth retardation and very highmortality. Under close care, some TKO mice, mostly females, do live toadulthood while about 80% of the TKO males suffer sudden death within2-6 months. The male adults are fertile and can be used for producingTKO offspring. We further demonstrated that the TKO mice have a reducedtolerance for cholestatic stress by feeding female TKO mice a 0.5%cholic acid diet, a condition that can be well-tolerated by bsep^(−/−)females and mdr1a^(−/−)/1b^(−/−) double KO mice. The female TKO miceunder a 0.5% CA diet became terminally ill or died after 3-7 days offeeding (FIG. 2). This is in sharp contrast with the bsep^(−/−) mice,the females of which could sustain 105 days of the same feedingconditions without showing any terminal illness (16).

The histological presentation of the TKO mice also indicates a much moresevere cholestasis in TKO mice than in bsep^(−/−) mice. Under amicroscope, the hepatocytes of TKO mice show readily visible periportalfibrosis (FIG. 1 c) and paucity of bile ducts (17 bile ducts per 91portal veins in TKO mice vs. 68 per 165 counted in wild-type mice).Using electron microscopy, profound hepatic damage was further observedin both plasma membrane and cytoplasm (FIG. 1 d). The TKO mice exhibitedmore severe defects as manifested by severely impaired canalicului thathave lost almost all microvilli, and dilated canalicular spaces filledwith dense bile substances. The hepatocytes of TKO mice also displaycytoplasmic abnormalities typical of hepatic toxicity with distortedmitochondria, hypertrophied Golgi apparatus, increased smoothendoplasmic reticulum, excessive lipid droplets, and increased numbersof peroxisomes (FIG. 4).

To determine whether or not Mdr1 is also a physiologically relevantcanalicular bile salt transporter that helps to alleviate an otherwisemore severe cholestatic phenotype, we selectively blocked Mdr1(P-glycoprotein) with the P-glycoprotein blocker Cyclosporine A (CsA) inbsep_(−/−) mice, in which the major canalicular bile salt transporterBsep is inactivated. Peritoneal injection of 25 mg/kg/day CsA induced amore severe cholestatic phenotype, including jaundice, rapid weight lossand a typically cholestatic liver biochemical profile of liverindicators similar to PFIC2 (Table 1). This observation of CsA-inducedcholestasis in bsep^(−/−) knockout (KO) mice indicates that Mdr1 isindeed a physiologically relevant bile salt transporter. However, thepossibility remained that the cholestatic effects of CsA on bsep^(−/−)mice are due to nonspecific toxicity of the compound rather thanspecific inhibition of Mdr1 mediated bile salt transport. CSA-treatedwild-type mice were not noticeably affected by the treatment.

The serum biochemical profile for liver function of the TKO miceresembles PFIC2, and differs from that of bsep^(−/−) mice in which nosuch abnormalities were seen (18). Examination of the plasma liverindicator profile of TKO mice showed low γ-GT, about 2-fold higheralkaline phosphatase (Table 1) and severe cholestasis comparable to thepresentation of human PFIC2. The TKO mice had serum bilirubin levels onaverage about 13 times that of the wildtype controls. The changes in ALTand AST were relatively small, which again agrees with what is found inPFIC2 patients (27, 28), who usually have very poor biliary secretion ofbile salt with high alkaline phosphatase and bilirubin, and low ornormal γ-GT in serum. The TKO mice therefore are a good model for thephysiological consequences of completely abolished bile salt secretionsuch as that found in human PFIC2.

TABLE 1 Liver biochemical indicators in bsep^(−/−), and wildtype femalemice treated with Cyclosporine A for two weeks, bsep^(−/−) mdr1a/b^(−/−)Triple Knockout mice, bsep^(−/−), mdr1a/b^(−/−), and wildtype femalemice fed a normal diet or fed a 0.5% CA-supplemented diet (n = 4)Genotype Bilirubin (mg/dl) ALP (U/L) γ-GT (U/L) ALT (U/L) AST (U/L) CsABsep^(−/−)  36.4 ± 0.783  142 ± 1.14 1.90 ± 1.96 59.9 ± 57.5  106 ± 54.0(0.193E−10) (0.0128) (0.690) (0.0783) (0.663) WT  1.28 ± 0.262 93.2 ±17.3  2.30 ± 0.984 11.4 ± 6.16 143 ± 102 Normal TKO 18.2 ± 5.45 409 ±131 1.52 ± 1.47 56.9 ± 35.9  150 ± 59.7 diet (0.193E−03) (0.871E−02)(0.120) (0.113) (0.584) Mdr1a/b^(−/−)  1.25 ± 0.397 64.8 ± 9.46 4.15 ±2.71 63.1 ± 64.6 168 ± 102 (0.669) (0.202E−07) (0.667) (0.274) (0.509)bsep^(−/−) 0.935 ± 0.197 277 ± 117 2.03 ± 1.01 58.7 ± 50.1 71.5 ± 29.5(0.0392) (0.174) (0.298) (0.223) (0.265) WT  1.35 ± 0.245  185 ± 22.03.42 ± 2.22 24.2 ± 8.40  126 ± 82.9 CA TKO 19.4 ± 3.34 630 ± 121  1.11 ±0.521 300 ± 127 850 ± 296 diet (0.890E−08) (0.239E−06) (0.452) (0.121)(0.0427) Mdr1a/b^(−/−) 0.505 ± 0.125  180 ± 31.3 0.467 ± 0.308  105 ±21.0  179 ± 66.1 (0.0848) (0.143) (0.116) (0.391) (0.322) Bsep^(−/−) 1.47 ± 0.384 697 ± 216 0.822 ± 0.749  405 ± 86.5 525 ± 139 (0.250)(0.330E−03) (0.310) (0.505E−02) (0.301) WT  1.07 ± 0.639  205 ± 19.71.81 ± 1.70 157 ± 128 344 ± 343 ALP—alkaline phosphatase γGT—γ-GlutamylTranspeptidase ALT—Alanine aminotransferase AST—Aspartateaminotransferase CA—cholic acid CsA—cyclosporine A All numbers areexpressed as a mean ± standard deviation (P value) (n = 3-6). Asterisksindicate statistical significance determined by two-tailed Student's ttest between the knockout and the wild-type mice in the same group.

To evaluate the extent of molecular changes in the hepatocytes of theTKO mice, we measured their gene expression profiles usingsemi-quantitative real-time PCR. TKO mice displayed a typicalcholestatic response, similar to what was found in the bsep KO mice(FIG. 5). We found that Mrp3 and Mrp4, the major basolateral bile salttransporters for clearance of bile salt from hepatocytes into thesinusoidal blood circulation, are greatly upregulated, as is the genemost likely to function as the major bile salt hydroxylase, Cyp3a11.Down regulation of Cyp3a41 and Cyp3a44 were also noted. Surprisingly,real-time PCR also detected elevated mdr1 transcription. We sequencedthe residual mdr1 transcripts and they consist of two alternativelyspliced isoforms, the major one with an exon 4 deletion (SEQ ID NO: 4),directing translation of an N-terminal fragment of 38 amino acids,followed by a frame shift, coding sequence for 7 novel amino acids and apremature stop codon (SEQ ID NO: 5); the less abundant transcript has adeletion of exons 4, 5, and 6 (SEQ ID NO: 6), resulting in translationof 38 original amino acids followed by a frame shift, 12 novel aminoacids and a premature stop codon (SEQ ID NO: 7).

We also examined the expression of MDR1, along with some other ABCtransporters, in PFIC patients of all subtypes. We reasoned that if MDR1were indeed a physiologically relevant bile salt transporter in humans,intrahepatic bile salt accumulation in PFIC patients should result inMDR1 upregulation. If that were the case, one could stimulate the bilesalt transport activity mediated by MDR1 clinically, to alleviatecholestasis. We compared liver biopsies from pediatric PFIC patientsfrom six age-matched controls with non-cholestatic liver diseases,including glycogen storage disease, urea cycle disorders, hepatitis, anda non-tumor liver sample from a hepatoblastoma patient. The controlswere not expected to have biliary secretion abnormalities. Assay byquantitative real-time PCR of the biopsy samples revealed a significantincrease of MDR1 expression in PFIC patients to approximately four timesgreater than the average control (Table 2). This increased expression ofMDR1 was further confirmed by immunofluorescent staining where asignificant increase of human BSEP protein was detected in thecanalicular membrane of the PFIC patients (FIG. 6). The results indicatethe presence of a physiologically redundant system for biliary bile saltsecretion in both mouse and man.

TABLE 2 Relative expression levels of canalicular transporters in PFICpatients in comparison toage-matched controls ABCB1 BSEP ABCB4 ABCC2ABCC3 ABCC4 age (MDR1) (BSEP) (MDR3) (MRP2) (MRP3) (MRP4) PFIC-1 I694N10 m 2.426 8.826 12.303 1.318 0.947 3.350 185-282de1 5 m 3.129 9.27211.322 1.871 0.517 4.380 Q1131X/556- 7 m 1.221 12.249 12.479 0.838 0.36016.618 628de1 PFIC-2 V284L/1145T 8 m 1.053 2.780 5.397 1.009 1.320 2.854del V284L/1145T 14 m 1.327 2.638 12.887 0.843 1.511 2.198 delG1004D/R487H 8 m 1.879 5.189 5.661 1.377 1.523 3.147 PFIC-3 A * 5 m2.105 4.597 2.323 0.527 0.937 0.879 B * 2 m 2.532 2.119 1.636 0.6660.958 4.537 287-1005del 6.5 y 3.300 2.979 1.346 0.960 1.540 1.899Paediatric control 0.365 ± 0.074  3.019 ±10.466 2.071 ± 0.484 1.818 ±0.589 0.963 ± 0.279 0.729 ± 0.244 (n = 6) *PFIC-3 patients diagnosed bytheir pathological and biochemical presentation. Relative mRNA levels oftransporters are expressed as fold change relative to TBP mRNA levels ineach sample (Mean ± SD for controls).

The properties of mutant mice were compared to PFIC2 patients (Table 3).

TABLE 3 Phenotypes Bsep KO Triple KO PFIC2 PGP(MDR1) Very high no Veryhigh expression Liver Size enlarged enlarged Enlarged Bile acids in bile¼ of normal — <1% of normal Bile flow Near normal blocked — Jaundice nosevere severe GGT normal low or normal low or normal ALP/ALT/AST normalhigh high

A significant upregulation of BSEP expression was found in livers ofPFIC patients.

EXAMPLE 2 Synthesis of taurine-conjugated 3α,6β,7β,12α-hydroxy bile acid

A taurine-conjugated 3α,6’,7β,12α-hydroxy bile acid, essentially a12α-hydroxylated version of β-muricholate, was synthesised as set out in(29-31). Isomers were produced simultaneously in the synthesis, and werelikely to have similar activities. Therefore, at least five additionalderivatives, specifically 3α,6α,7α,12α-; 3α,6β,7α,12α-; 3α,6α,7β,12α-;3α,6β,7β,12α-; 3α,6α,7α,12β-hydroxy derivatives of the above compoundwere also isolated. The isolated compounds were labeled using is³H-labelling bile salts by hydrogen exchange in a solution oftritium-enriched water, followed by re-isolation of the labeled bilesalt (a service available from Perkin-Elmer, for example) (32). Theisolated compounds were tested for their relative affinities fortransport via MDR1 in vitro, as described herein. The most efficaciouscompound in vitro was isolated in larger quantities and used as the leadcompound for the in vivo tests of toxicity and efficacy described hereinor known in the art.

1. Synthesis of taurine-conjugated 3α,6α,7α,12α-tetrahydroxy-5βcholanoicacid

Referring to FIG. 10, 3α,6α,7α,12α-tetrahydroxy-5β-cholanoic acid (7)was protected as an acetate (16). Under an N₂ atmosphere, taurine wasactivated with N-hydroxysuccinimide in the presence of organic base andacetate (16), worked up with 0.1 N NaOH and washed through Serdolit™-1,to provide amide (17). Amide (17) was treated with 1 N NaOH, for 40minutes at 80° C., followed by 20 minute at 50° C., and 1.5 hr at 25°C.; yielding taurine conjugate (18) after washing through Serdolit™-1.¹H-NMR spectrum of taurine conjugated3α,6α,7α,12α-tetrahydroxy-5βcholanoic acid (18) is shown in FIG. 11.

EXAMPLE 3 Evaluation of Transport Kinetics and Interactions

The transport kinetics and interactions of compounds, produced asdescribed herein, with their transporter MDR1, are evaluated incomparison to the widely used therapeutic bile acid ursodeoxycholate aswell as taurocholate, the primary bile acid in humans and mice andβ-muricholate, a tri-hydroxy bile acid not normally found in humans.Membrane vesicle systems derived from CHO B30 cell membranes, a line ofChinese Hamster Ovary cells selected for its considerable amplificationof the Mdr1 locus and corresponding drug resistance are used, as well asvesicles from the human SKOV series of cell lines, also selected forMDR1 overexpression. This experimental system is well established. Usingthis system ATP-dependent uptake of ³H-labeled bile acids into vesicles,either alone or in combination with interacting compounds such astaurocholate or ursodeoxycholate, is measured. Humans and rodents do notdiffer significantly in the drug-resistance profiles mediated by theirrespective MDR1 P-glycoproteins, therefore using both human androdent-cell derived vesicles confirms that any differences in novel bileacid transport kinetics between the species does not significantly altertheir expected utility. Any bile acid less hydrophobic (and thereforeless toxic) than taurocholate, but with a higher affinity thantaurocholate (lower K_(m)) for transport by MDR1 is of potentialtherapeutic benefit e.g., tetra-hydroxylated bile acids show a suitablemix of low-toxicity and high capacity for transport by MDR1.

Modulation of transporter affinity for bile salts is also a mechanism bywhich muricholates and tetra-hydroxylated bile acids overcomecholestasis. A bile acid according to the invention may allostericallyreduce the K_(m) of MDR1 for cholate, and so further increase its valueas a choleretic agent. Such effects on MDR1 are examined using isolatedmembrane vesicles in the presence of the various bile acids and alsopotential stimulators such as rhodamine 123, Hoechst 33342 or prazosin,known to interact with Mdr1 at separate sites (33-35). Uptake kineticsof commercially available ¹⁴C-taurocholate into B30 membrane vesicles inthe presence of various concentrations of potential modulators arecompared. Positive modulation increases the uptake rate. Drugs known tobe Mdr1 substrates are screened. Drug-bile acid and bile acid-bile acidinteractions are characterized to determine if the K_(m) fortaurocholate transport has decreased.

EXAMPLE 4 Determination of Maximum Tolerated Dose In Vivo

The maximum tolerated dose of bile acid according to the invention wasdetermined. This test is carried out in two ways. First, as a pilotexperiment of bile duct cannulation, a bolus of bile acid was infusedinto mice under anesthesia to measure its acute toxicity to animals. Theresponses of mice such as breath rate, bile flow rate, histologicalchanges by H&E staining and the like were recorded. For taurocholate ourtests indicated that 167 μmol/kg of body weight delivered intravenously,was the maximum tolerated dosage. Using this tolerance level as areference point, the acute toxicity of the bile acid was determined. Themaximum tolerated dosage (MTD) for intravenously administeredursodeoxycholate was found to be 65 μmol/kg of body weight. This isconsistent with it being a less toxic bile salt. The LD50 forintravenously administered ursodeoxycholate in mice has been reported tobe ˜600 μmol/kg.

Therapeutic doses of ursodeoxycholate in humans are usually given orallyand typically do not exceed 40 μmol/kg/ of body weight per day. Further,orally administered bile acid may be less toxic as it enters thebloodstream and thus the liver at a slower rate than would occur withintravenous administration. The oral LD50 for ursodeoxycholate inrodents is at least 15 times greater than when given intravenously,giving considerable safety margin against overdose. Bile acids showingeven greater affinity for Mdr1 than muricholates or cholates have agreater dose-specific effect on enhancing bile flow under conditions ofBsep dysfunction, while demonstrating lower toxicity at any given dose.

Chronic toxicity is tested by supplementing the diets of mice (wild-typeas well as the hypersensitive bsep KO mice) with 0.1%-0.5% β-muricholateor bile acid according to the invention. Control feeding experiments usecholate as well as ursodeoxycholate. Wild-type mice can endure the extrabile salt loading of a 0.5% cholate indefinitely, while the same dietwill cause female bsep KO mice to lose weight, and kills male bsep KOmice within 10 days (16, 18). A 0.5% cholate diet will kill even femaleTKO mice within a week (36). Animals are fed control and bileacid-supplemented diets and monitored daily for weight loss and weeklyfor serum indicators of liver function to detect symptoms of cholestasissuch as elevated liver enzymes in blood, as well as elevated bile saltsand/or bilirubin (Table 1). Bile duct cannulations are also conducted inwhich a bolus of ¹⁴C-taurocholate is injected into the tail veins ofmice, either alone or together with a novel bile acid, and the kineticsof ¹⁴C-taurocholate appearance in the bile measured and the in vivoeffect of each novel bile acid upon taurocholate transport by Mdr1and/or Bsep is evaluated.

EXAMPLE 5 Amelioration of Cholestasis In Vivo

The effectiveness of bile acids according to the invention is assessedin a whole animal system that allows the influence of molecular andphysiological events affecting bile salt transport and bile flow. Acombination of unique knockout mouse lines is used to test whether thenovel bile salts can alleviate the cholestatic stress by promoting Mdr1-mediated bile flow. Three lines of KO mice are used. As describedherein, the bsep KO mouse carries an inactivated bsep gene but haselevated mdr1a/1b expression; the mdr1a/mdr1b double KO mouse havenormal bsep expression but inactivated mdr1a/1b genes; and thebsep/mdr1a/mdr1b triple KO mouse (TKO) has all three genes inactivated.These three lines of animals are used to verify the in vivo cholereticfunction of the novel bile acid in alleviating cholestatic pressure.

Small amounts of ³H-labelled THBAs, of various isomers, prepared asdescribed herein, are injected into the mutant mouse strains (pluswild-type controls), and radioactivity recovered in blood, urine, bileand hepatocytes are measured in order to compare the in vivo kinetics ofthe novel THBAs to those obtained for the same compounds in vitro, asdescribed herein. The mice are challenged with a high dose of a bileacid according to the invention, selected on the basis of the kineticexperiments described above. Concentrations of 0.5%-1.5% are used in thediet, given that the same amount of taurocholate (a substrate preferredby Bsep) can be tolerated indefinitely by wild-type mice. The mice aremonitored according to their body weight, morbidity, mortality, liverindicator profile, and liver histology as reported previously (16, 18,37) (Table 1). In addition, the bile of animals being fed the bile acidaccording to the invention is collected, and analyzed by HPLC. Increasein the amount of bile flow is a direct measure of the cholereticpotential of the bile acid according to the invention, and changes inthe bile acid composition of bile in the three KO mouse strains indicatethe extent to which bile acid according to the invention is transportedby Mdr1 versus Bsep in vivo. Changes in the proportions of biliary bileacids other than the bile acid according to the invention itself, ifobserved, indicate modulatory effects of the bile acid according to theinvention on the transport or synthesis of the conventional bile acidpool.

High dose feeding has fewer negative effects than taurocholate on bsepKO mice, moderate toxicity towards mdr1a/1b mice and high toxicity forTKO mice. Previously, we have found that bsep KO and TKO mice arehypersensitive to taurocholate feeding. If feeding with the novel bileacid according to the invention is less toxic to bsep KO mice thantaurocholate feeding, we will then challenge our mutant mice withmixtures of the bile acid according to the invention and cholate orursodeoxycholate in order to provide direct in vivo evidence for thetherapeutic value of the bile acid according to the invention.

EXAMPLE 6 Synthesis of 3α,6α,7α,12α-tetrahydroxy-5β-cholanoic acid and3α,6β,7α,12α-tetrahydroxy-5β-cholanoic acid

We have synthesized three forms of bile acid:3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid,3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid and3α,6β,7β,12α-tetrahydroxy-5β-cholan-24-oic acid. The following synthesesare based on those reported by Iida et al. and Aggarwal et al. (61, 62,and references cited therein), and Gouin et al., Fieser et al., Putz etal., Narasimhan et al. and Omatein et al. (66-70 and references citedtherein). This chemistry has been performed on a multi-gram scale andminor modifications have been made to the experimental and purificationprocedures in order to optimize yields. The final compounds werepurified by flash chromatography and were greater than 95% pure (asindicated by NMR analysis). They have also been shown to be homogeneousby HPLC methods.

1. Synthesis of 3α,6α,7α,12α-tetrahydroxy-5β-cholanoic acid

Protection of cholic acid (1) afforded the methyl ester (2) that wasoxidized with N-bromosuccinimide (NBS) to the corresponding ketone (3).This compound was then protected as the diacetate (4) and converted tothe key intermediate (5) on reaction with molecular bromine. Thisbromide was then hydrolyzed to the hydroxyl-ketone (6). Subsequentreduction and global deprotection of the acetate and methyl estermoieties afforded the target compound (7).

2. Synthesis of 3α,6β,7α,12α-tetrahydroxy-5β-cholanoic acid

The intermediate (5), see above, was reduced with zinc borohydride andthe resultant bromohydrin was reduced further with metallic zinc toafford the corresponding alkene (8). Treatment of the latter compoundwith meta-chloroperoxybenzoic acid (m-CPBA) afforded the epoxide (9).Lewis acid-mediated ring opening of this compound afforded the diol(10). Subsequent global deprotection afforded the target compound (11).

3. Alternate method of synthesis of3α,6α,7α,12α-tetrahydroxy-5β-cholanoic acid

Referring to FIG. 9, oxidation of cholic acid (1) with NBS providedcorresponding ketone (12) followed by protection to afford thecorresponding methyl ester (3). This compound was then protected as anacetate (4′), and subsequently, acetate (4) and converted tointermediate (5) by reaction with molecular bromine. The bromide washydrolyzed to the hydroxyl-ketone (13). Subsequent reduction anddeprotection afforded the target compound (7).

EXAMPLE 7 3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid stimulatesbile flow rate (BFR) in wild-type mice

For bile duct cannulation, wild type mice on the genetic background ofFVB/NJ were weighed and anesthetized by intraperitoneal injection ofKetamine (112.5 mg/kg) and Xylazine (11.3 mg/kg) after 2-4 hours offasting. The abdomen was opened, and the gall bladder was cannulatedusing a PE-10 catheter after distal common bile duct ligation [63, 64].After 20 minutes of bile flow equilibration, bile was collected intopre-weighed tubes at 5-minute intervals for 10 minutes. A bolus of3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid (6α,7αTHBA, pH.7.4-7.6),3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid (6β,7αTHBA, pH.7.4-7.6),ursodeoxycholic acid (UDC, pH.7.4-7.6) or cholic acid (100 μmol/kg bodyweight) was then infused into the tail vein over a 20-second interval.Bile was then further collected through the cannula at 2-minuteintervals for 10 or 20 minutes, followed by 10-minute intervals for 30minutes. The bile flow rate was calculated by weighing the tubescontaining the collected bile. Bile collected was used for HPLCanalysis.

UDC solution for the infusion was freshly made within 2 hours prior tothe experiments, and was made as follows: for each milliliter of 100 mMUDC solution, 39.62 mg of UDC (Sigma U5127) was vortex-mixed in sequencewith 86.6 μl of 100% ethanol, 86.6 μl of 1N NaOH, and 826 μl of 0.9%NaCl solution. Different working solution are diluted from the 100 mMsolution. The pH of the solution was 7.4-7.6.

FIG. 7. 3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid stimulates bileflow rate (BFR) in wild-type mice. (A) BFR as a function of body weightin mice after infusion of 3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oicacid (THBA). (B) BFR as a function of body weight in mice after infusionof cholic acid (CA) (3α,7α,12α-trihydroxy-5β-cholan-24-oic acid). Abolus of THBA or CA (100 μmol/kg body weight) was infused into the tailvein over a 20 second interval at 10 minutes. Results are presented asthe mean (μ/100 g of body weight)±the standard deviation.

Bile flow rate (BFR) was determined before and after infusion of3α,6β7α12αtetrahydroxy cholanoic acid (6β,7αTHBA) at a dose of 65, 250,350 and 400 μmol/kg body weight (BW) (FIG. 12A); or infusion of3α,6α7α12αTHBA (6α,7a THBA) of 65 and 200 μmol/kg BW (FIG. 12B). FIG.12C illustrates BFR as a function of body weight before and after theinfusion of 65 μmol/kg body weight of 6β,7αTHBA, 6α,7αTHBA andursodeoxycholic acid (UDC). Results are represented as the mean±thestandard deviation of three mice.

During bile duct cannulation experiments, we have found that UDC infusedthrough the tail vein at a concentration of 70 μmol/kg body weight orhigher caused death of wild-type mice under anesthesia (Ketamine, 112.5mg/kg and Xylazine, 11.3 mg/kg). We thus determined that UDC at 65μmol/kg of body weight as administrated through a bolus tail veininfusion was the maximum tolerated dose (MTD) in the mice. However, thewild-type mice can tolerate 6β,7αTHBA infusion at 500 μmol/kg of bodyweight (highest dosage tested) and 6α,7αTHBA infusion at 400 μmol/kg ofbody weight (highest dosage tested) without death. The maximum tolerateddoses of 6β,7αTHBA (MTD>500 μmol/kg of body weight) and 6α,7αTHBA(MTD>400 μmol/kg of body weight) were several times higher than that ofUDC.

UDC at 65 μmol/kg body weight is the maximum tolerated dose (MTD) in themice, resulting in a bile flow rate similar to that observed by infusionof a similar quantity of 6β,7αTHBA or 6α,7αTHBA. Infusion of increasingquantities of 6β,7αTHBA or 6α,7αTHBA, results in a correspondingincrease in bile flow rate (FIGS. 12A, B).

FIG. 8. HPLC (High Performance Liquid Chromatography) profiles of bilefractions collected from a wild-type mouse before (A), and 2-4 minutesafter (B), infusion (100 μmol/kg) of3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid. FIG. 8C shows HPLCprofiles of bile fractions collected from a wild-type mouse before(upper trace), and 2-4 minutes after (lower trace), infusion (100mmol/kg) of cholic acid.

HPLC was carried out with a Waters 600 pump and controller and a 486 UVdetector. Separation was performed on a Spherisorb S5 ODS2 C-18 (5 mmparticle size, 250 mm×4 mm, Waters) reverse phase analytical column andwas preceded by guard column (Nova Pack, Waters). Integration of thepeaks was carried out using Millennium 2010 software. The bile saltcontrols were separated at ambient temperature over 48 minutes at a flowrate of 0.6 mL/min and 3200 psi. The mobile phase consisted of solvent A(MeOH) and solvent B (60:40 MeOH: 0.01 M potassium phosphate, 0.02 Msodium phosphate (pH 5.35 (modified from Rossi et al. 1987 J Lipid Res28(5): 589-95; Hagey et al. 1998. J Lipid Res 39(11): 2119-24). Initialconditions were held at 100% B for the first 25 minutes. Over the next10 minutes, there was a linear gradient to 30% B and conditions wereheld for another 5 minutes. The conditions then decreased through alinear gradient to 100% A over 8 minutes. The system was flushed with100% MeOH followed by equilibration back to the initial conditions. Theeffluent was monitored at 210 nm.

For visualizing the 3α,6α,7α,12α-THBA, 4 μl bile was dissolved in 20 ulmethanol, and injected into a buffer stream at 0.6 mL/minute, and readby absorbance at a wavelength of 210 nm. The buffer was 60% methanol,40% 0.1M KH₂PO₄, 0.02M NaH₂PO₄ pH5.35 [65]. For visualizing cholic acid,the procedure was the same as for 3α,6α,7α,12α-THBA initially, but after5 minutes the buffer was stepped linearly to a mixture of 20%methanol:80% buffer within 4 minutes, held constant for another 10minutes, then stepped linearly within 2 minutes to 30% methanol:70%buffer for the duration of the run.

Therefore, tetrahydroxy-5β-cholan-24-oic acids(3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid) promotes bile flow inwild-type mice. As demonstrated by High Performance LiquidChromatography (HPLC), 3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acidis metabolized by taurine-conjugation in vivo and secreted into the bileminutes after being infused into the mouse tail vein (FIG. 8A, B). Thissuggests that this bile acid can be metabolized and detoxified by thesame pathways that metabolize native bile acids and mediate theirsecretion across the canalicular membrane.

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Other Embodiments

The present invention has been described with regard to one or moreembodiments. However, it will be apparent to persons skilled in the artthat a number of variations and modifications can be made withoutdeparting from the scope of the invention as defined in the claims.Therefore, although various embodiments of the invention are disclosedherein, many adaptations and modifications may be made within the scopeof the invention in accordance with the common general knowledge ofthose skilled in this art. Such modifications include the substitutionof known equivalents for any aspect of the invention in order to achievethe same result in substantially the same way. Numeric ranges areinclusive of the numbers defining the range. In the specification, theword “comprising” is used as an open-ended term, substantiallyequivalent to the phrase “including, but not limited to,” and the word“comprises” has a corresponding meaning. Citation of references hereinshall not be construed as an admission that such references are priorart to the present invention. All publications are incorporated hereinby reference as if each individual publication was specifically andindividually indicated to be incorporated by reference herein and asthough fully set forth herein. The invention includes all embodimentsand variations substantially as hereinbefore described and withreference to the examples and drawings.

1. A method of treating a biliary disorder or stimulating bile flow in asubject in need thereof, the method comprising administering atherapeutically effective amount of a compound according to Formula I:

or a derivative thereof, wherein any one of R₁ to R₉ may be —H or —OH,provided that at least four of R₁ to R₉ are —OH; and R₁₀ may be —COON or—CH₂OH.
 2. The method of claim 1 wherein said compound comprises ahydrophilicity greater than that of cholate.
 3. The method of claim 1wherein said compound is selected from the group consisting of atetrahydroxylated bile acid and a pentahydroxylated bile acid, or aderivative thereof.
 4. The method of claim 3 wherein saidtetrahydroxylated bile acid is selected from the group consisting of a3,6,7,12-tetrahydroxycholanoic acid, a 3,4,7,12-tetrahydroxycholanoicacid, a 1,3,7,12-tetrahydroxycholanoic acid, a2,3,7,12-tetrahydroxycholanoic acid, a 3,7,16,24-tetrahydroxycholanoicacid, and a 3,7,15,24-tetrahydroxycholanoic acid, or a derivativethereof.
 5. The method of claim 4 wherein said3,6,7,12-tetrahydroxycholanoic acid is selected from the groupconsisting of a 3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6α,7β,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6β,7β,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6α,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, a3α,6β,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, and a3α,6β,7β,12β-tetrahydroxy-5β-cholan-24-oic acid, or a derivativethereof.
 6. The method of claim 1 wherein said compound has apreferential affinity for MDR1 when compared to BSEP.
 7. The method ofclaim 1 wherein said compound has a high affinity for MDR1.
 8. Themethod of claim 1 wherein said compound is a conjugated compound.
 9. Themethod of claim 8 wherein said conjugated compound is a taurine or aglycine conjugate.
 10. The method of claim 1 wherein said compound isselected from the group consisting of a tauryl or glycyl conjugate of a3α,6β,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, a tauryl or glycylconjugate of a 3α,6β,7β,12β-tetrahydroxy-5β-cholan-24-oic acid, and atauryl conjugate of a 3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid.11. The method of claim 1 wherein said compound is a tauryl conjugate ofa 3α,6β,7β,12α-tetrahydroxy-5β-cholan-24-oic acid.
 12. The method ofclaim 1 further comprising administering at least one other therapeuticagent.
 13. The method of claim 12 wherein said other therapeutic agenthas a preferential affinity for BSEP.
 14. The method of claim 12 whereinsaid other therapeutic agent is ursodeoxycholate.
 15. The method ofclaim 1 wherein said biliary disorder is selected from the groupconsisting of benign biliary strictures, benign pancreatic diseasecysts, diverticulitis, liver fibrosis, liver damage, common bile ductstones, pancreatitis, pancreatic cancer or pseudocyst, periampullarycancer, bile duct carcinoma, primary sclerosing cholangitis, autoimmunecholangitis, extrinsic duct compression (e.g., compression due to a massor tumor on a nearby organ), viral hepatitis, sepsis, bacterial abscess,use of drugs e.g., drug-induced idiosyncratic hepatotoxicity, lymphoma,tuberculosis, metastatic carcinoma, sarcoidosis, amyloidosis,intravenous feeding, primary biliary cirrhosis, primary sclerosingcholangitis, alcoholic hepatitis with or without cirrhosis, nonalcoholicsteatohepatitis, nonalcoholic fatty liver disease, chronic hepatitiswith or without cirrhosis, intrahepatic cholestasis of pregnancy,biliary calculosis, biliary dyscinesia, Sjogren syndrome, Wilson'sdisease, ischemia, toxins, alcohol, acute liver failure, α1-antitrypsindeficiency, PFIC2, Benign Recurrent Intrahepatic Cholestasis,hepatocellular carcinoma, portal hypertension, veno-occlusive disease,and hepatic vein thrombosis.
 16. The method of claim 1 wherein saidbiliary disorder arises or potentially arises from cholestasis.
 17. Themethod of claim 1 wherein said subject is a human.
 18. A pharmaceuticalor nutritional composition comprising a compound according to Formula I:

or a derivative thereof, together with a pharmaceutically acceptablecarrier, wherein any one of R₁ to R₉ may be —H or —OH, provided that atleast four of R₁ to R₉ are —OH; and R₁₀ may be —COOH or —CH₂OH.
 19. Thecomposition of claim 18, wherein said compound comprises ahydrophilicity greater than that of cholate.
 20. The composition ofclaim 18, wherein said compound is selected from the group consisting ofa tetrahydroxylated bile acid, a pentahydroxylated bile acid, or aderivative thereof.
 21. The composition of claim 20, wherein saidtetrahydroxylated bile acid is selected from the group consisting of: a3,6,7,12-tetrahydroxycholanoic acid, a 3,4,7,12-tetrahydroxycholanoicacid, a 1,3,7,12-tetrahydroxycholanoic acid, a2,3,7,12-tetrahydroxycholanoic acid, a 3,7,16,24-tetrahydroxycholanoicacid, and a 3,7,15,24-tetrahydroxycholanoic acid, or a derivativethereof.
 22. The composition of claim 21, wherein said3,6,7,12-tetrahydroxycholanoic acid is selected from the groupconsisting of: a 3α,6α,7α,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6α,7β,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6β,7β,12α-tetrahydroxy-5β-cholan-24-oic acid, a3α,6α,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, a3α,6β,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, and a3α,6β,7β,12β-tetrahydroxy-5β-cholan-24-oic acid, or a derivativethereof.
 23. The composition of claim 18, wherein said compound has apreferential affinity for MDR1 when compared to BSEP.
 24. Thecomposition of claim 18, wherein said compound has a high affinity forMDR1.
 25. The composition of claim 18, wherein said compound is aconjugated compound.
 26. The composition of claim 25, wherein saidconjugated compound is a taurine or a glycine conjugate.
 27. Thecomposition of claim 18, wherein said compound is selected from thegroup consisting of: a tauryl or glycyl conjugate of a3α,6β,7α,12β-tetrahydroxy-5β-cholan-24-oic acid, a tauryl or glycylconjugate of a 3α,6β,7β,12β-tetrahydroxy-5β-cholan-24-oic acid, and atauryl conjugate of a 3α,6β,7α,12α-tetrahydroxy-5β-cholan-24-oic acid.28. The composition of claim 18, wherein said compound is a taurylconjugate of a 3α,6β,7β,12α-tetrahydroxy-5β-cholan-24-oic acid.
 29. Thecomposition of claim 18, further comprising at least one othertherapeutic agent.
 30. The composition of claim 29, wherein said othertherapeutic agent has a preferential affinity for BSEP.
 31. Thecomposition of claim 29, wherein said other therapeutic agent isursodeoxycholate. 32-35. (canceled)
 36. An article of manufacturecomprising a compound according to Formula I:

or a derivative thereof, together with instructions for use in treatinga biliary disorder or stimulating bile flow, wherein any one of R₁ to R₉may be —H or —OH, provided that at least four of R₁ to R₉ are —OH; andR₁₀ may be —COOH.